What CPT 99231 represents in IDR
Subsequent hospital care with straightforward or low level of medical decision making, per.
For IDR strategy, the code-level view matters because payer behavior can look different after the QPA, state, and service category are held constant. Use this page to compare your CPT 99231 disputes against the CMS benchmark before escalating volume.
CPT 99231 outcomes by state
| State | Disputes | Provider win rate | Median award | Median award dollars |
|---|---|---|---|---|
| California | 885 | 90% | 68.2x | $4,500 |
| New York | 538 | 70.6% | 106.0x | $4,800 |
| New Jersey | 335 | 82.3% | 79.8x | $4,800 |
| Texas | 253 | 92% | 6.5x | $270 |
| Florida | 115 | 85.4% | 3.7x | $147 |
| Arizona | 92 | 82.9% | 6.2x | $274 |
| Missouri | 71 | 60.6% | 14.4x | $272 |
| Colorado | 70 | 92.1% | 6.6x | $389 |
| Nevada | 40 | 91.7% | 110.7x | $5,000 |
| North Carolina | 15 | 92.3% | 2.7x | $200 |
| South Carolina | 6 | 83.3% | 7.5x | $200 |
| Georgia | 6 | 75% | 4.0x | – |
Top payers for CPT 99231
| Payer | Disputes | Provider win rate | Median award |
|---|---|---|---|
| Anthem Blue Cross | 563 | 86.7% | 63.4x |
| UnitedHealthcare | 542 | 82.4% | 67.1x |
| Aetna | 418 | 91.7% | 36.7x |
| Cigna / MultiPlan | 267 | 80.3% | 49.6x |
| BLUE SHIELD OF CA | 197 | 76% | 73.8x |
| Cigna | 89 | 85.7% | 70.2x |
| UMR (clearhs.com) | 80 | 80.3% | 8.6x |
| BCBSTX | 43 | 90% | 12.4x |
| gmail.com | 43 | – | 81.2x |
| 1199funds.org | 33 | 43.3% | 122.5x |
Recent CPT 99231 quarterly trend
| Quarter | Disputes | Provider win rate | Median award |
|---|---|---|---|
| 2024Q3 | 163 | 88% | 20.4x |
| 2024Q4 | 251 | 86.8% | 21.2x |
| 2025Q1 | 365 | 83.8% | 53.1x |
| 2025Q2 | 581 | 83.5% | 72.8x |
| 2025Q3 | 527 | 85.7% | 93.9x |
| 2025Q4 | 440 | 77.2% | 95.1x |
Filing checklist before you take CPT 99231 claims to IDR
- Confirm the claim is NSA-eligible: emergency care, or out-of-network care at an in-network facility, with no state arbitration law that displaces the federal process for that plan type.
- Start open negotiation within 30 business days of the initial payment or denial notice. The negotiation window then runs 30 business days.
- If negotiation fails, initiate federal IDR through the portal within 4 business days after the window closes.
- Batch same-payer items in the same service code category. Open negotiation periods starting on or after November 1, 2026 can batch up to 50 line items per dispute, up from 25.
- Budget for fees: the federal administrative fee is $15 per party for disputes initiated on or after June 11, 2026 (down from $115), and the non-prevailing party pays the certified IDR entity fee.
- Anchor your offer to the data: the CPT 99231 median provider-won award is 55.7x QPA across 2,465 disputes.
The fee and batching changes come from the May 2026 federal IDR operations final rule. See the 2026 and 2027 No Surprises Act changes guide for the full timeline, or request a free NSA audit to see how your claims compare.
Open CPT 99231 in the explorer
Filter CPT 99231 by state, year, and payer to compare the public benchmark with your own out-of-network payment experience.
FAQ
How many CPT 99231 disputes are in the benchmark?
The page shows 2,465 federal IDR disputes.
What is the CPT 99231 median IDR award?
The median provider-won award is 55.7x QPA.
Is CPT 99231 always eligible for federal IDR?
No. The code is only one screen. Eligibility also depends on payer, plan type, setting, state-law routing, patient protections, and deadlines.
What does it cost to take a CPT 99231 claim to federal IDR in 2026?
The federal administrative fee is $15 per party for disputes initiated on or after June 11, 2026, down from $115. The non-prevailing party also pays the certified IDR entity fee, so a benchmark-backed offer matters before filing.
Related benchmarks
Sources and method
Providers won 85.8% of 3.39 million federal IDR disputes through 2025Q4, with a median provider-won award of 4.7x the qualifying payment amount, per CMS public use files.
- CMS: Federal IDR reports and public use files
- CMS: Federal IDR operations final rule fact sheet
- CMS: Federal IDR timeline for claims
Data source: CMS Federal IDR public use files, coverage through 2025Q4; data build 2026-09-24. Counts are CMS dispute counts unless a table says line items. Win rates on this page exclude payer no-show defaults unless labeled otherwise. Award multiples are medians versus the qualifying payment amount (QPA). Dollar figures, where shown, come from CMS QPA-and-offer fields or are anchored estimates, not payment records. This page is informational, not legal or reimbursement advice.